Extracorporeal blood oxygenation and ozonation (EBOO) in man. preliminary report

Autohemotherapy with ozone has been used for four decades with encouraging results but, owing to the lack of clinical studies, it has never been adopted by orthodox medicine. Confident of the valid principles of ozone therapy, we have endeavoured to increase its therapeutic efficacy. Over a ten-year period we have developed an apparatus that makes it possible to treat large quantities of blood with ozone in extracorporeal circulation (extracorporeal blood oxygenation and ozonation EBOO). One of us volunteered to test the system and after six treatments noted the disappearance of two lipomas. This prompted us to treat a patient with Madelung disease and several patients with atherosclerotic vasculopathy. Besides showing therapeutic effects, the preliminary results indicate that EBOO is clinically valid, without side-effects and worthy of testing in various diseases.     

Necrotizing fasciitis successfully treated with extracorporeal blood oxygenation and ozonization (EBOO)

A case of necrotizing fasciitis in a dialysis patient is described. Since traditional therapies were unsuccessful, extracorporeal blood oxygenation and ozonation (EBOO) was tried. This technique is no longer in the experimental stage and is used routinely in our hospital. Patient condition improved radically after EBOO.     

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.     

Efficacy and safety of galantamine (reminyl) for dementia in patients with Parkinson's disease (an open controlled trial)

An open controlled trial of the use of galantamine at a maximum dose of 16 mg/day included 41 patients with Parkinson's disease with dementia randomized to a galantamine treatment group (21 patients) and a control group (20 patients). Cognitive, neuropsychiatric, and motor symptoms were assessed clinically before the trial and at 4, 12, and 24 weeks, using the Mini Mental State Examination (MMSE), the cognitive Alzheimer's Disease Assessment Scale (ADAS-cog), the clock drawing test, the Frontal Assessment Battery (FAB), and the Neuropsychiatric Inventory (NPI) with assessment of distress in relatives. Patients treated with galantamine had better scores on the MMSE (p < 0.05),ADAS-cog (p < 0.05), the clock drawing test (p < 0.05), and the FAB (p < 0.01) at the end of the study period as compared with the control group. Changes in total point scores on the NPI-12 at the ends of weeks 12 and 24, as compared with the beginning of the trial, were in favor of the group treated with galantamine, with significant changes in the hallucinations (p = 0.0002), anxiety (p = 0.04), sleep disturbance (p = 0.04), and apathy (p = 0.006) sections. Galantamine treatment was accompanied by decreases in the level of distress in patients' relatives (p = 0.007) and improvements in daily activity (p = 0.003). Improvements in gait and decreases in freezing and falls were seen in the galantamine treatment group. However, two patients of this group showed minor increases in tremor. Side effects (drooling, postural hypotension, nausea, dysuria) occurred in seven patients (30%). __________ Translated from Zhurnal Nevrologii i Psikhiatrii imeni S. S. Korsakova, Vol. 107, No. 12, pp. 25–33, December, 2007.     

Predictors of increased transfusion requirements and optimizing transfusional support in patients on Extracorporeal membrane oxygenation (ECMO)

ECMO has an established role in neonatal, paediatric and adult patients with cardiac and/or respiratory failure who failed to respond to conventional therapies. It provides temporary cardiopulmonary support until the recovery of the patients or the institution of definitive treatment. Patients undergoing ECMO, especially adults, have high requirements for all blood components. High transfusional needs have been associated with increased mortality in the adults. Neonatal patients generally have lower overall transfusion requirements than the adults. The significant transfusion requirements among ECMO patients is contributed by increased bleeding from the need for systemic anticoagulation to reduce circuit thrombosis, activation and consumption of platelets and clotting factors, and anaemia from haemodilution and haemolysis. The need to prime the ECMO circuit with red cells may also account for part of the neonatal transfusion requirements There can be wide inter-individual variations in the transfusion requirements of ECMO patients. Differences in pre-determined transfusion triggers may account for differences in blood utilization between centers. Central cannulation can be associated with higher cannulation bleeding rates and blood utilization than peripheral cannulation. In neonates, factors associated with increased daily platelet transfusions include the use of venoarterial ECMO and the presence of concomitant sepsis and meconium aspiration. Neonates with sepsis or congenital diaphragmatic hernia may have the highest overall platelet transfusions due to longer ECMO duration. Neonates with intracranial haemorrhage were observed to require more platelet transfusions. In our retrospective analyses of adult ECMO patients in a cardiothoracic surgical unit in Singapore, there were positive correlations of total red cell, platelet and FFP transfusions with ECMO duration which in turn increased in non-surgical or septic patients. On multivariate analyses, nadir haemoglobin of <7.5 g/dL associated with increased average daily red cell and FFP transfusions. Recent antiplatelet usage and maximum haemoblobin decline of >5.5 g/dl while on ECMO independently associated with increased average daily platelet transfusions. In addition, increased ECMO duration (which correlated negatively with nadir platelet count) was also independently associated with average daily transfusion of >3 platelet concentrate units. Bleeding was not an independent factor associated with any of the blood component utilization. Our findings suggest that the patients' haemoglobin levels and the perceived need to minimize coagulopathies among patients with significant anaemia and/or additional bleeding risks may have the greatest impact on clinicians' transfusion decisions in adult patients undergoing ECMO. Measures including the use of activated recombinant factor VII to reduce haemorrhage, and reduction in allogeneic blood transfusion with the use of an autotransfusion device during elective changes of ECMO systems have been reported to reduce transfusion requirements. Close collaboration between the transfusion service and the ECMO team is necessary to optimize the transfusion support of patients undergoing ECMO.     

Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease

BACKGROUND: Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge. Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes. We report the first randomised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme (CDSMP) (Expert Patient Programme) - in a south Asian group. AIM: To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease. DESIGN OF STUDY: Randomised controlled trial. SETTING: Tower Hamlets, east London. METHOD: We recruited Bangladeshi adults with diabetes, cardiovascular disease, respiratory disease or arthritis from general practices and randomised them to the CDSMP or waiting-list control. Self-efficacy (primary outcome), self-management behaviour, communication with clinician, depression scores, and healthcare use were assessed by blinded interviewer-administered questionnaires in Sylheti before randomisation and 4 months later. RESULTS: Of the 1363 people invited, 476 (34%) agreed to take part and 92% (439/476) of participants were followed up. The programme improved self-efficacy (difference: 0.67, 95% confidence interval [CI] = 0.08 to 1.25) and self-management behaviour (0.53; 95% CI = 0.01 to 1.06). In the 51% (121/238) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy (1.47; 95% CI = 0.50 to 1.82) and self-management behaviour (1.16; 95% CI = 0.50 to 1.82), and reduced HADS depression scores (0.64; 95% CI = 0.07 to 1.22). Communication and healthcare use were not significantly different between groups. The programme cost pound123 (181) per participant. CONCLUSION: A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease. Effects on health status were marginal. Benefits were limited by moderate uptake and attendance.     

A controlled clinical trial with De-Nol (tripotassium dicitrato bismuthate) in patients with gastric ulcer

The efficacy of local-acting De-Nol liquid (tripotassium dicitrato bismuthate) was investigated in patients with endoscopically verified gastric ulcer. In a prospective-type clinical trial, 16 outpatients received De-Nol and 24 outpatients received an antacid mixture (sodium bicarbonate, calcium carbonate, magnesium trisilicate in equal parts). The period of study was 4 weeks, the endoscopy being performed on the 14th and 28th day after commencement of treatment. We Registration was made of the degree of ulcer healing (ulcer is healed, or not healed but reduced by 50%, or slightly healed, or unchanged), the degree of pain (0 = none, 1 = slight, 2 = moderate, 3 = severe), body weight, different biochemical and haematological examinations, side-effects and some other parameters. Of those patients given De-Nol treatment, the ulcer healed in 69% within four weeks, as compared with 33% of those given antacid therapy. There was also a significant (p less than 0.001, p less than 0.02) difference between the two groups in the size of the ulceration which remained and in the decrease of pain. Side-effects were not recorded. These data suggest the beneficial effect of De-Nol liquid in the treatment of patients with gastric ulceration.     

Activated T and B lymphocytes in peripheral blood of patients with Chagas' disease

Whole blood preparations from patients with either the indeterminate(asymptomatic) or cardiac clinical forms of chronic Trypanosomacruzl infection were analyzed by flow cytometry using double-labelingto identify subsets of circulating lymphocytes. Several significantdifferences were demonstrated between the blood lymphocyte profilesof chagaslc patients and non-chagaslc controls. Clear increasein the percentages and actual numbers of double-positive cellsof the phenotype CD3⁺/HLA-DR⁺, as well as decrease in the percentageof CD45RA⁺/CD4⁺ and CD45RA⁺/CD8⁺ T cells, Indicate greater numbersof activated T cells circulating in the blood of infected patients.Consistent parallel increases were seen also in the B lymphocytesubset which stained double-positive for CD19/CD5. There wereno significant differences in the circulation of these chronicchagaslc patients in the CD4:CD8 ratios. Also, no substantivephenotyplc differences were observed in the lymphocyte populationsbetween the two ends of the clinical spectrum (Indeterminateversus cardiac) in chronic human Chagas' disease. These observationsdemonstrate that increased levels of activated T cells and CD5⁺B cells are present in the circulation of people with chronicChagas' disease. These are cell phenotypes that have been associatedin other conditions with autoimmune, polyclonal, and hyperlmmuneresponses. The specificities of these activated cells and theroles they may play in resistance or pathogenesis during chronicChagas' disease need now to be determined.     

Extracorporeal membrane oxygenation and extracorporeal albumin dialysis in pediatric patients with sepsis and multi-organ dysfunction syndrome

Extracorporeal membrane oxygenation (ECMO) is used in managing patients with potentially reversible cardio-respiratory failure refractory to conventional methods. Multiorgan dysfunction syndrome (MODS), usually due to sepsis, remains the main cause of mortality in such patients. We report a series of six pediatric patients with sepsis-induced MODS where extracorporeal albumin dialysis (EAD) was used while the patients were on ECMO. The age of the patients ranged between 1 month and 17 years. The mean pediatric index of mortality (PIM) score at admission was 67.5%. All these patients further deteriorated with MODS and EAD was used as rescue therapy. At institution of EAD, 4 patients had dysfunction of 4 organs and 2 patients had dysfunction of 5 organs. The number of EAD cycles ranged between 1 and 3. Three out of the 6 patients (50%) survived to discharge from the intensive care unit and two of the six patients (33%) survived to hospital discharge. According to our previous experience and published results, all these patients would have been expected to die. The present results suggest that EAD may prove to have a role in the treatment of pediatric patients with sepsis-induced MODS. Further research is required to identify the group of patients who would benefit most by EAD as well as understand the clearance of inflammatory mediators and other mechanisms involved with the use of EAD.     

Manual lymphatic drainage improves the quality of life in patients with chronic venous disease: a randomized controlled trial

Introduction

Manual lymphatic drainage (MLD) is an adjunctive method of chronic venous disease (CVD) therapy. Evaluation of the change at the clinical stage, hemodynamic parameters and quality of life (QoL) following venous system surgery in CVD patients undergoing MLD preoperatively are the most interesting aspects of the study.

Material and methods

The CVD patients qualified for elective surgery of the venous system were randomly divided into 2 groups: the MLD group (n = 38) and the control group (n = 32). In the preoperative period, the MLD group underwent a series of MLD through a period of 2 weeks. The control group did not undergo MLD preoperatively. Both groups were evaluated for CVD staging on the day of qualification for surgery and between 25 and 30 days post-operatively. Additionally, the MLD group was evaluated after the series of MLD. The CVD staging was evaluated in both groups with a QoL questionnaire (CIVIQ), CEAP classification, foot volumetry (FV) and venous refilling time (VRT).

Results

Parameter values obtained in the MLD group (before treatment/after MLD/after surgery): CEAP 2.23/2.15/2.10, VRT 15/13/15.6, FV 3625/3472/3418, CIVIQ-complaints: 54.4/43.8/38.2 and CIVIQ-meaning: 57.3/49.3/43.1. Parameter values obtained in control group (before surgery/after surgery): CEAP 2.4/2.12, VRT 13/14.9, FV 3581/3559, CIVIQ-complaints: 51.9/38.7 and CIVIQ-meaning: 53.7/40.6. The CVD patients statistically improved in CEAP staging, FV and QoL in both groups (p < 0.05).

Conclusions

The MLD alone significantly reduced FV in patients with CVD, also improving their QoL. The MLD applied in CVD patients at the preoperative stage results in better surgical outcome, which is demonstrated by reduced disease progression, FV reduction and improvement in the QoL.     

IL-27在Graves病患者外周血中的表达

为了探讨IL-27与Graves病发病的关系检测了Graves患者外周血单个核细胞中IL-27p28/EBI3mRNA的表达和外周血血清中IL-27的水平。收集Graves患者及健康对照者抗凝外周静脉血,分离外周血单个核细胞(peripheral blood mononuclear cells,PBMC),采用实时定量PCR(real-time PCR)技术,检测IL-27p28/EBI3mRNA的表达;通过收集Graves患者及正常对照者外周静脉血,采用酶联免疫吸附试验(enzyme linked immunosorbent assay,ELISA)检测血清中IL-27的水平。结果显示:1、与对照组相比,IL-27p28/EBI3mRNA在Graves患者外周血PBMC中的表达升高(P0.05)。2、Graves患者血清中IL-27水平较健康对照者升高(P0.05)。3、血清中IL-27水平与促甲状腺素受体抗体滴度之间无相关性(P0.05)。因此,我们推测IL-27参与了Graves的发病,未来仍需进一步的研究阐明IL-27在Graves中发挥的具体作用。     

Comparison of methadone and buprenorphine for opiate detoxification (LEEDS trial): a randomised controlled trial

Background

Many opiate users require prescribed medication to help them achieve abstinence, commonly taking the form of a detoxification regime. In UK prisons, drug users are nearly universally treated for their opiate use by primary care clinicians, and once released access GP services where 40% of practices now treat drug users. There is a paucity of evidence evaluating methadone and buprenorphine (the two most commonly prescribed agents in the UK) for opiate detoxification.

Aim

To evaluate whether buprenorphine or methadone help to achieve drug abstinence at completion of a reducing regimen for heroin users presenting to UK prison health care for detoxification.

Design

Open-label, pragmatic, randomised controlled trial in three prison primary healthcare departments in the north of England.

Method

Prisoners (n = 306) using illicit opiates were recruited and given daily sublingual buprenorphine or oral methadone, in the context of routine care, over a standard reduced regimen of not more than 20 days. The primary outcome measure was abstinence from illicit opiates at 8 days post detoxification, as indicated by urine test (self-report/clinical notes where urine sample was not feasible). Secondary outcomes were also recorded.

Results

Abstinence was ascertained for 73.7% at 8 days post detoxification (urine sample = 52.6%, self report = 15.2%, clinical notes = 5.9%). There was no statistically significant difference in the odds of achieving abstinence between methadone and buprenorphine (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 0.81 to 3.51; P = 0.163). Abstinence was associated solely with whether or not the participant was still in prison at that time (15.22 times the odds; 95% CI = 4.19 to 55.28). The strongest association for lasting abstinence was abstinence at an earlier time point.

Conclusion

There is equal clinical effectiveness between methadone and buprenorphine in achieving abstinence from opiates at 8 days post detoxification within prison.     

Extracorporeal membrane oxygenation with a poly-methylpentene oxygenator (Quadrox D). The experience of a single Italian centre in adult patients with refractory cardiogenic shock

Although microporous polypropylene hollow fiber oxygenators are standard devices used for extracorporeal membrane oxygenation (ECMO), they have limitations such as development of plasma leakage. Poly-methylpentene (PMP) is a new material used for the last generation of oxygenators. We reviewed our experience with a new PMP oxygenator (Quadrox D) and a centrifugal pump (RotaFlow) used to support adult patients with refractory cardiogenic shock. Between January 2000 and April 2007, 25 patients required ECMO for primary or postcardiotomy cardiogenic shock. Eighteen patients were analyzed [mean age 60.2 years; 11 (61%) men; 7 (39%) women]. Nine patients (50%) suffered primary cardiogenic shock. Cardiopulmonary resuscitation was applied in 11 patients (61%) with a mean duration time of 31.5 minutes. Mean ECMO duration time was 7.1 +/- 6.3 days (range, 1-27 days). Intra-aortic balloon pump was used in 13 patients (72.2%) with a mean duration time of 7.7 +/- 5 (range, 2-17 days). Twelve patients (66.7%) survived on ECMO and five patients (27.8%) were discharged. Our results indicate the PMP oxygenator and the centrifugal pump provided acceptable results in terms of surviving on ECMO and discharge. Patients with an initial catastrophic hemodynamic status could benefit by means of a rapid institution of ECMO with PMP oxygenators.     

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial

Objective

To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).

Methods

Semi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.

Results

38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.

Conclusion

Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.

Practice implications

Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.     

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial

ObjectiveTo explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).MethodsSemi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.Results38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.ConclusionTelemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.Practice implicationsPatients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.     

Serum levels of lipoprotein (a) and other lipids in angiographically defined coronary artery disease patients and healthy blood bank donors

Lipoprotein (a) (Lp(a)) and other lipid values have been correlated with angiographically defined [table: see text] coronary artery disease. To study this relationship in Indian patients, plasma levels of Lipoprotein (a) and other lipids were assessed in 74 patients undergoing Coronary arteriography and also in 53 age and sex matched healthy male blood bank donors who served as controls. Total cholesterol (mg/dl) (211 +/- 56 vs 186 +/- 43; p < 0.001), low density lipoprotein Cholesterol (mg/dl) (117 +/- 40 vs 88 +/- 29; p > 0.001) and low density lipoprotein/high density lipoprotein cholesterol ratio (2.6 +/- 0.8 vs 2.2 +/- 0.9; p < .001) were significantly higher in patients than controls. High density lipoprotein-cholesterol (mg/dl) (43.5 +/- 6 vs 42.1 +/- 7; p-ns) very low density lipoprotein-cholesterol (mg/dl) (49.7 +/- 17 vs 56.1 +/- 25; p-ns) and triglycerides (mg/dl) (155 +/- 101 vs 167 +/- 88; p-ns) were not statistically different in two groups. Lipoprotein (a) levels showed highly skewed distribution. Patients (n = 74) showed almost five fold higher lipoprotein (a) levels (mg/dl) as compared to controls (n = 53) [105 +/- 565 vs 23 +/- 76]. Patients with very high lipoprotein (a) levels [values of more than 40 mg/dl] (n = 18) had high density lipoprotein cholesterol and total cholesterol significantly lower than rest of the patient group. [high density lipoprotein cholesterol (mg/dl) 41.00 +/- 3.7 vs 44 +/- 6.4; p < 0.01 and total cholesterol (mg/dl) 192 +/- 34 vs 217 +/- 53; p < 0.05].